1. Study of Head and Neck Cancer two-week wait referral pathway
Gruber EA, Anand P, Harding SA, Courtney DJ.
Oral and Maxillofacial Department, Derriford Hospital, Plymouth, PL6 8DH
Introduction
The two-week waiting time standard was introduced in ‘The New NHS – Modern, Dependable’1 in 1997 and guarantees all patients with suspected cancer will be able to see a specialist within two weeks of their GP requesting an urgent appointment. This was implemented for head and neck cancer in December Since then the two-week wait has been a topic of interest and concern to clinicians with many wondering if the referrals are appropriate or non-urgent. This audit aimed to investigate these concerns.
Aims were to assess:
Whether the two-week wait referral forms were completed adequately
If the pathway was efficient in detecting head and neck cancer
Method
A retrospective review of all two-week wait referral forms for suspected head and neck cancer (Figure 1) received by the Oral and Maxillofacial Surgery and ENT Surgery Departments at Derriford Hospital, Plymouth over a seven-month period was undertaken.
Gender and age were recorded in order to investigate demographic patterns
Risk Factors were recorded to assess adequate completion of relevant data
Primary and systemic symptoms were noted in order to compare with histology
Interpretation of the proficiency of form completion was achieved through focus group discussion. The focus group consisted of three SHO’s, two SpR’s, a Consultant and a Researcher. Quantitative data was entered into SPSS Version 15 for descriptive analysis.
Figure 1
Results
292 patients (144 Male; average age of all patients 57.6yrs) presented via the two-week wait
referral pathway over the seven-month period.
The referral forms were often insufficiently completed by Primary Care Practitioners, especially
regarding smoking. 41 forms (14%) did not have any smoking category selected. The section on alcohol consumption was also poorly completed, with 5.5% (N=16) being reported as being heavy drinkers, but an additional 12.3% (N=36) had no response to this question. Indeed on twelve forms no symptoms were reported. On the remaining forms an average of 1.3 symptoms were reported.
44% of all urgently referred patients were discharged from the outpatient clinic following the initial appointment without any further investigations.
130 (45%) patients had histology performed, 101 of these on an urgent basis, 29 on a routine basis. 26 (9%) of these revealed malignancy. Figure 2 shows the location of samples sent to histology and whether they were benign or malignant.
When the reported symptoms for those being referred for histology were correlated (using
Spearmans Rho Correlation Coefficient), significant relationships (P< 0.001) were found between
hoarseness and neck mass, neck lump, and oral swelling; also between weight loss and
anaemia. No difference in this pattern was found between those diagnosed as malignant and
those found to be benign.
The mean age for patients with benign histology was 57.0 years and with malignancy 67.9 years,
which are significantly different (p<0.003, Mann-Whitney U test).
Discussion
Early diagnosis and treatment of cancer is generally regarded as beneficial in terms of morbidity and mortality, and is one of the reasons the two-week wait directive
was implemented. The referral pathway was therefore developed to rapidly identify patients with malignancy. The sheer numbers referred using this pathway suggest
that it is a welcome initiative but that the yield of significant histology is low – 26 cases in 292 referrals. The surprisingly low proportion of malignancies identified
through the two-week wait pathway leads us to believe that the waiting times for patients referred non-urgently and for problems other than cancer may be I
inappropriately prolonged. Previous studies reveal a similar low percentage of malignancies detected via the two-week wait referral pathway2,3,4. Almost half the patients
did have histology performed following assessment by a hospital Specialist, therefore their referral was valid.
Although specific forms have been developed for General Practitioners to guide their referrals, they are poorly completed. This means that the data provided to the
hospital Consultants is at best limited and at worst inaccurate.
Conclusion
A review of the referral form is required in order to elicit more complete referral information. This redesign may also prove to be a useful educational tool for General
Practitioners by highlighting visual features that would be suggestive of malignancy. This should be done with reference to the NICE guidelines for oral cancer
symptoms. Further study is needed to assess the number of cancers detected via the routine referral pathway.
References
1. Secretary of State for Health. The New NHS – Modern, Dependable. London: Stationery Office; 1997.
2. An audit of two week wait referrals for head and neck cancer. Williams RW, Hughes W, Felmingham S, Irvine GH. Ann R Coll Surg Engl (Suppl) 2002; 84:
3. Audit of referrals for head and neck cancer – the effect of the 2-week, fast track referral system. Lyons M, Philpott J, Hore I, Watters G. Clin Otolaryngol Allied Sci 2004; 29(2):
4. Fast-track referrals for oral lesions: a prospective study. Shah HV, Williams RW, Irvine GH. Br J Oral Maxillofac Surg. 2006; 44(3):
Our kind thanks to the Dallas Morning News and Jed Hunsaker for the images of Wile E Coyote and the Roadrunner, and to Chuck Jones for memorable original animations :-)